T the 2006 annual meeting of the AANS, the YoungNeurosurgeons Committee organized a surgicalcompetition using three different emerging simula-

tors for residents and fellows in the exhibit hall. Ventricu-lostomy was one of the techniques tested,15 and the resultsof this testing are reported here. The performance of 78fellows and residents was evaluated for accuracy of ventric-ulostomy catheter placement using the head- and hand-tracked high-resolution and high-performance virtual real-ity and haptics workstation known as ImmersiveTouch(ImmersiveTouch, Inc.) and a virtual patient’s head derivedfrom a CT data set.

Ventriculostomy is a high-volume, low-morbidity tech-nique and is often the first neurosurgical procedure that ayoung neurosurgery resident will learn and perform on aregular basis. While faculty members or senior residentsmay proctor early cases, the high volume of the procedure

means that most residents must become proficient very ear-ly in their training. Our haptic-technology–based, 3D sim-ulator for ventriculostomy placement recreates the surfacelandmarks that guide catheter trajectory as well as the tac-tile feedback as the catheter passes through the brain paren-chyma and into the ventricle.10,13

The ImmersiveTouch augmented virtual reality systemwas developed at the University of Illinois at Chicago12 andcombines real-time haptic feedback with high-resolutionstereoscopic display. An electromagnetic head-trackingsystem provides dynamic perspective as the user moves hisor her head. A half-silvered mirror is used to create an aug-mented reality environment that integrates the surgeon’shands, the virtual catheter, and the virtual patient’s head ina common working volume while eliminating occlusions.

Clinical Material and Methods

Selection Criteria

Participants consisted of 78 fellows and residents select-ed by the Young Neurosurgeons’ Committee at the 2006AANS annual meeting through an open solicitation. They

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J Neurosurg 107:515–521, 2007

Accuracy of ventriculostomy catheter placement using ahead- and hand-tracked high-resolution virtual realitysimulator with haptic feedback

P. PAT BANERJEE, PH.D.,1–3 CRISTIAN J. LUCIANO, M.S.,1,2 G. MICHAEL LEMOLE JR., M.D.,4

FADY T. CHARBEL, M.D.,4 AND MICHAEL Y. OH, M.D.5,6

Departments of 1Mechanical and Industrial Engineering, 2Bioengineering, and 3Computer Science,College of Engineering, University of Illinois at Chicago; 4Department of Neurosurgery, University of Illinois Medical Center at Chicago, Illinois; 5Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania; and 6Department of Neurosurgery,West Virginia University, Morgantown, West Virginia

Object. The purpose of this study was to evaluate the accuracy of ventriculostomy catheter placement on a head- andhand-tracked high-resolution and high-performance virtual reality and haptic technology workstation.

Methods. Seventy-eight fellows and residents performed simulated ventriculostomy catheter placement on anImmersiveTouch system. The virtual catheter was placed into a virtual patient’s head derived from a computed tomog-raphy data set. Participants were allowed one attempt each. The distance from the tip of the catheter to the Monro fora-men was measured.

Results. The mean distance (6 standard deviation) from the final position of the catheter tip to the Monro foramenwas 16.09 mm (6 7.85 mm).

Conclusions. The accuracy of virtual ventriculostomy catheter placement achieved by participants using the simula-tor is comparable to the accuracy reported in a recent retrospective evaluation of free-hand ventriculostomy placementsin which the mean distance from the catheter tip to the Monro foramen was 16 mm (6 9.6 mm).(DOI: 10.3171/JNS-07/09/0515)

KEY WORDS • haptic technology • neurosurgical simulation • ventriculostomy •virtual reality

A

515

Abbreviations used in this paper: AANS = American Associationof Neurological Surgeons; CT = computed tomography; SD = stan-dard deviation.

participated in a competition that featured a ventriculosto-my workstation based upon a head- and hand-tracked high-resolution and high-performance virtual reality and haptictechnology system known as ImmersiveTouch. Accuracyof simulated ventriculostomy catheter placement was eval-uated. The ImmersiveTouch software utilizes a series ofmodules to acquire, process, and render the graphic andhaptic data, which are then seamlessly integrated on thehardware platform. A virtual 3D volume of a human headwas created using data from a patient at the University ofIllinois at Chicago Medical Center. The data were preseg-mented and assembled from a CT DICOM data set after theremoval of all identifying personal data. The 3D polygonalisosurfaces corresponding to the skin, bone, brain, and ven-tricles were extracted.

The data are based on a one-time performance (singletrial) of each participant in inserting the catheter followinga detailed explanation during a period in which the partici-pants were permitted to observe other individuals’ perfor-mances and to ask detailed questions.

The haptic characteristics and graphic rendering for thesimulator were modified based on initial feedback frommembers of the neurosurgical faculty and senior residentsat the University of Illinois at Chicago before the devicewas used at the AANS annual meeting. The final productwas universally felt to simulate the tactile and visual com-ponents of the actual procedure.

Ventriculostomy Catheter Placement

In the ImmersiveTouch system, an electromagnetic sen-sor (Ascension Technologies Corp.) attached to the ste-reoscopic goggles tracks head movements to compute thecorrect viewer’s perspective while the user moves his or her head around the virtual patient’s head to locate the land-marks. Another sensor located inside the SpaceGrips (La-serAid) tracks the surgeon’s hand to define a cutaway planeand the light source to better view the virtual head volumeand its virtual contents.

Based on the position and orientation of the haptic sty-lus (SensAble Technologies, Inc.), collision detection be-tween the virtual catheter and the imported 3D isosurfacesis computed, and corresponding force feedback is gener-ated through the servomotors of the haptic device. Eachisosurface is assigned different haptic characteristics, ac-cording to the following parameters: stiffness, viscosity,static friction, and dynamic friction. Therefore, the surgeoncan feel the differences in skin, bone, and brain. A viscosityeffect is felt as the catheter passes through the gelatinousparenchyma of the brain. As soon as the catheter breaks thedense ependymal ventricular lining, the viscosity effect ceas-es, providing the surgeon with a distinct “puncturing” sen-sation.

The virtual patient’s head is displayed using the import-ed 3D isosurfaces. A perspective camera node allows thedisplay of stereoscopic perspective according to the user’sposition and head orientation. A cutaway tool on the Space-Grips device permits visualization of deeper surfaces andvolumes through synchronization with the user’s handmovement and wrist rotation. The graphic images are dis-played using a high-resolution cathode ray tube monitorand transreflective mirror. The ImmersiveTouch system of-fers high display resolution (1600 3 1200 pixels) and high

visual acuity (20/24.74), which is important for clear visu-alization of the depth markings of the virtual catheter andsmall details of the head anatomy. There is also a magni-fication option to help in reading the scale marking on thevirtual catheter, which is modeled after a Medtronic ven-tricular catheter.

The collocation of haptic and graphic informationachieved by the ImmersiveTouch is critical to the realisticrecreation of the surgical experience. The user sees his orher own hand holding a virtual catheter in the same loca-tion and space as it would appear during an actual ven-triculostomy procedure; there is no shift in anatomical per-spective as with endoscopy or previous computer-basedsimulations. The user can interact with the virtual objectsusing both hands: the surgeon holds the haptic stylus in onehand and defines arbitrary 3D cutting planes with the otherhand, which holds a SpaceGrips interface (Fig. 1).

The user sits at the worktable space in front of the Im-mersiveTouch simulator. The electromagnetically trackedCrystalEyes glasses (REAL D) are worn to stereoscopicallyview the reflected virtual reality image on the partially mir-rored viewing surface. Any movement of the user’s headcauses a corresponding change in perspective around thevirtual patient’s head. These changes also collocate with theuser’s hands as viewed through the transreflective (half-mir-rored) viewing surface. The virtual catheter and assortedvirtual working tools (light source, cutaway instruments,and dynamic perspective) also project into the collocationspace (Fig. 2).

The user is presented with a virtual patient’s head. Bygrasping the haptic stylette, he or she is able to see a virtu-al catheter with its appropriate measurement markings.This catheter is collocated in the user’s hand to convey theperception that he or she is actually holding a catheter.

The catheter tip is positioned over one of the four burhole selections (labeled east, west, north, and south) at ornear the Kocher point while the optimal trajectory is deter-mined (Fig. 3).

Measurement Technique

Data sets from CT studies performed in patients withovert hydrocephalus were selected to simplify the earlymodeling of the ventricular system. Future renditions willinclude normal and slit ventricles.

As the catheter is advanced past the calvaria and entersthe virtual model of the brain, the user feels a distinct in-crease in resistance. When the catheter reaches the appro-priate volumetric depth, there is a sudden release in hapticresistance corresponding to the puncture often experiencedwhen the ventricle is cannulated. The ruler markings on theventricular catheter may also be used to gauge the expect-ed depth to ventricular cannulation.

When the user thinks that the ventricular catheter hasbeen successfully placed, the SpaceGrip controller is usedto freeze the virtual catheter in position. If the virtual cath-eter is in the virtual ventricular system it turns green, oth-erwise it turns red. The user may then use the cutaway toolwhile moving and rolling the wrist as well as rotating his orher own head to visualize the exact location of the cathetertip and correlate the experience with technique (Fig. 4). Foreach participant, the final position and orientation of thecatheter were recorded in the computer.

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516 J. Neurosurg. / Volume 107 / September, 2007

Results

The mean Euclidean distance from the catheter tip to theMonro foramen in the 78 trials was 16.09 mm (SD 7.85mm), with a range from 2.68 to 49.62 mm. The mean dis-tance from the catheter tip to the center of the bur hole was63.63 mm (SD 13.45 mm). The measurements are given inTable 1.

As shown in Table 2, 57 (73%) of the 78 catheter tipssuccessfully reached the ventricle, and 21 (27%) of 78attempts were unsuccessful. Of the successful attempts, 22(38.5%) reached the anterior horn of the right lateral ven-tricle, three (5%) reached the anterior horn of the left later-al ventricle, 23 (40%) reached the body of the right lateralventricle, six (10%) reached the third ventricle, and three(5%) reached other regions of the ventricular system.Among the 48 attempts that reached the lateral ventricles,the catheter tips were ipsilateral in 45 (94%) and contralat-eral in three (6%).

The catheter tip was positioned over one of the four burhole selections (labeled east, west, north, and south) at ornear the Kocher point while optimal trajectory was deter-mined (Fig. 3). Fifty-three (68%) of the 78 participantschose west, 13 (17%) chose south, 11 (14%) chose east,and one (1%) chose north. Contrary to expectation, no sig-nificant differences were noticed in the mean distance fromthe final position of the catheter tip to the Monro foramenwith respect to choice of bur hole, so this choice did notplay a significant part in the participants’ performances.

Table 3 shows a directional frequency distribution of thefinal position of the tip of the catheter based on the threecardinal directions to determine trends in participant per-formances. For a total of 78 attempts (one attempt per par-ticipant), distribution in the left–right, anteroposterior, andsuperior–inferior directions with reference to the Monro

foramen are shown. A majority of the cannulation attemptswere toward the right side, anterior to and/or superior to theMonro foramina.

As shown in Table 4, there were no significant differ-ences in the distance from the final position of the cathetertip to the Monro foramen based on the direction of ap-

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FIG. 3. Virtual patient’s head. Three-dimensional reconstructionbased on CT data showing the four predrilled bur holes (East, West,North, and South).

FIG. 1. Photograph showing the ImmersiveTouch system in op-eration.

FIG. 2. Photograph demonstrating catheter insertion in the Im-mersiveTouch system.

proach. The means and SDs for the three directions arequite comparable.

Finally, we collected data to analyze the impact of thelevel of training on the participants’ performances. As seenin Fig. 5, there does not seem to be a strong correlationbetween the level of training as measured by the number ofyears in residency and performance. This finding is a bitsurprising; further studies are needed.

Discussion

The goal of imparting full procedural knowledge andpsychomotor skills has received a major boost with theadvent of surgical simulators.2,4,11,19,20 Ventriculostomy isone of the most frequently performed neurosurgical proce-dures.17 Diagnostic information about intracranial pressureis made available through the procedure. In addition, ven-triculostomy may provide lifesaving therapeutic drainagein cases of symptomatic intracranial hypertension. Clearguidelines have been established for the procedure in a va-riety of neurological diseases including obstructive hydro-cephalus and traumatic brain injury.14 Although performinga ventriculostomy is considered one of the most basic neu-rosurgical skills, the high volume and critical nature of theprocedure make proper technique particularly important.

Trajectory guides can improve catheter tip placementaccuracy without altering ventricular cannulation rates.16 In2000, Phillips and John developed a cross-platform, web-based ventriculostomy simulator.6,18 This early simulatorallowed virtual catheter positioning and trajectory determi-nation relative to a 3D virtual head. In lieu of tactile feed-back, an auditory cue signaled ventricular cannulation.Catheter manipulation with the mouse was rudimentary,and no tactile feedback was provided. This form of visual-ly reinforced learning for ventriculostomy training has al-so been described with reference to surgical neuronaviga-tional platforms.7 The effectiveness of these simulators islimited to improving the understanding of anatomical rela-tionships relative to catheter position and trajectory. Manyother simulation approaches have also been described.3,22

The first generation of haptic ventriculostomy simulatorsprovided tactile feedback using a haptic stylus device dur-ing virtual ventricular cannulation.9,22 The user manipulatedthe virtual catheter with the haptic stylus in a haptic and vir-tual reality environment implemented for the Reachin dis-play (Reachin Technologies AB). Although this develop-ment created considerable excitement as a novelty devicefor ventricular cannulation, its usefulness for teaching andmeasuring neurosurgical expertise was very limited. Morerecent efforts using haptic-driven ventriculostomy simu-lators have attempted to correlate simulator training with

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TABLE 1Euclidean distance measurement statistics

(in mm) for catheter placement

Catheter Tip to Catheter Tip toParameter Monro Foramen Center of Bur Hole

mean 16.09 63.63min 2.68 30.00max 49.62 120.00SD 7.85 13.45

FIG. 4. Workstation images of virtual patient’s head during sim-ulated ventriculostomy. Successful ventricular entry (A) is indicat-ed by the catheter turning green; after an unsuccessful attempt (B),the catheter turns red to indicate failure. Also shown is a cutawayview (C) for examination

increased procedural efficacy. Despite graphical “near-to-reality” characteristics, these systems still require “suspen-sion of disbelief” in the user.21 The reasons and how wehave overcome these issues are provided in the followingdiscussion.

An important feature of realistic simulation is perfectoverlap of the virtual catheter 3D image with the haptic sty-lus. This effectively collocates the virtual catheter withinthe same space as the haptic stylus so that the user feels asthough he or she is holding the catheter. This collocatedperspective takes into account the user’s head positionthrough head tracking. Previous attempts at ventriculosto-my simulation were not able to address this issue, and theattention of the surgeon was diverted from the simulatedprocedure toward overcoming the visual dissociation ofreal and virtual objects. In effect, the device did not ade-quately reproduce the ventriculostomy procedure.

The ImmersiveTouch platform appears to resolve theseissues.10 The simulation is very realistic, as demonstratedby good correlation with previous experience among neu-rosurgical faculty members, residents, and medical stu-dents. If there was no correlation with the psychomotorskill set involved in placing a ventriculostomy, then theuser’s experience should not affect initial success with thissimulator. More importantly, the simulator appears to“jumpstart” the learning process by providing immediateand corrective feedback so that real improvement can bemeasured. The most critical components of this virtual real-ity simulation of ventriculostomy placement include ren-dering of actual clinical data, stereoscopic 3D display withdynamic perspective tracking, collocation of real and virtu-al object space, and tactile feedback through haptic model-ing.

The results from this ImmersiveTouch experiment at the2006 annual meeting of the AANS can be utilized toaddress an important challenge in validation of ventricu-lostomy simulation through comparison with clinical ven-triculostomy data. Fortunately, Huyette and colleagues5

have recently performed a retrospective evaluation of thehead CT scans performed in 97 patients who underwent98 freehand ventriculostomy placements in an intensivecare unit setting at the University of Missouri in Columbia.This makes the task of comparison with clinical data quitemeaningful. At the outset it is recognized that because the

ventriculostomy simulation is part-task, a direct compari-son with the clinical procedure is not very meaningful. Inthis paper we report an indirect comparison utilizing theprimary strength of the simulation approach and the prima-ry strength of the clinical approach, namely the ease ofrepeating the same simulated ventriculostomy procedurefor multiple participants, thereby controlling experimentvariability in the simulation approach and the ease of ret-rospectively examining multiple clinical ventriculostomycases and enhancing realism through clinical approach.

The similarity of the values obtained for mean error asmeasured by the distance between the final position of thecatheter tip and the Monro foramen of about 16 mm andSD of approximately 7 to 9 mm in both the ventriculosto-my simulator and freehand clinical ventriculostomy seemsto be a significant observation. Whether this observationindicates a trend in these studies with moderate samplesizes is an interesting research question. A similar magni-tude of mean error and SD in a set of approximately 80 par-ticipants using the simulator and about 100 clinical casescan provide an initial hypothesis regarding the degree towhich a simulator can replicate the experience of an actualclinical case and can serve as a basis for further studiesinvolving more patients.

We observed that the ipsilateral lateral ventricle wasmore often the site of entry in both simulated and clinicalcases. A review of our simulated cases showed a contralat-eral/ipsilateral lateral ventricle site ratio of 3:45, which iscomparable to the ratio observed in the clinical setting byHuyette and colleagues.5 This finding is expected giventhat a frequent target for ventricular catheter placement iswithin the ipsilateral frontal horn just anterior to the Monroforamen.1

With respect to reaching the ventricle, there was no sig-nificant difference between the success rate observed in ourstudy using the simulator (73%) and the success rate in theclinical setting as reported by Huyette and associates(79%).5 It should be noted that the simulator results arebased on the performance of participants drawn from apool made up primarily of residents, whereas the clinicalresults were more likely to be based on the performance ofsenior and experienced neurosurgeons. Once again this rep-resents an interesting initial observation on how closely asimulator can capture a real situation. Given the fact thatthe initial success rates are roughly similar, it is possiblethat the simulator could be used to represent cases of com-plexity equivalent to those encountered in the clinical set-ting.

In our study each participant was allowed only one at-tempt. In a frequently cited study, Krotz and coworkers8

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TABLE 2Frequency classification of the final positionof the catheter tip in 78 placement attempts*

Position Catheter Tip

third ventricle 6anterior horn of rt lateral ventricle 22anterior horn of lt lateral ventricle 3body of rt lateral ventricle 23body of lt lateral ventricle 0posterior horn of rt lateral ventricle 0posterior horn of lt lateral ventricle 0fourth ventricle 0other areas of the ventricular system 3outside of the ventricles 21

* Values represent the number of times the final position of the catheteror its tip was at the given anatomical location.

TABLE 3Directional frequency distribution of the final positionof the catheter tip with respect to the Monro foramen

Relative Position No. of Attempts

rt (2X direction) 58lt (1X direction) 20anterior (2Y direction) 51posterior (1Y direction) 27superior (2Z direction) 52inferior (1Z direction) 26

reported a mean of 1.3 attempts per successful placementwith CT-guided ventriculostomy and 1.5 attempts withconventional ventriculostomy. Thus our experiment im-posed a more stringent condition.

As noted before, the 98 ventriculostomy procedures stud-ied by Huyette and colleagues5 were performed in 97 differ-ent patients, whereas in our study the 78 participants at-tempted the simulated procedure in one virtual patient. Thestrength of the virtual reality approach is the capacity forstandardization, that is, multiple participants all attemptingthe procedure in what amounts to a single case; the weak-ness is that it is a part-task simulator.

Although the part-task simulator can certainly demon-strate an individual’s spatial skill in placing a catheter, itcannot be used to measure the temporal skill. Ventricularcatheters are normally placed in emergency settings and be-cause the procedure can be life-saving, time is of the es-sence in addition to accuracy.

There does not seem to be a strong correlation betweenthe level of training as measured by the number of years inresidency and performance, as shown in Fig. 5. Furtherstudy is required to explain this finding. A possible expla-nation is that accuracy may be determined by the actualnumber of procedures performed rather than the level oftraining.

Conclusions

We have introduced a new realistic haptic-technology–based, augmented, virtual reality simulator for neurosurgi-cal education in general and ventriculostomy training inparticular. The ImmersiveTouch system creates a virtualreality environment using stereoscopic, perspective-basedrendering, haptic feedback, and virtual/real-world objectcollocation. The simulator accurately reproduces the part-task experience of cannulating the ventricle with a virtualventricular catheter. Given the importance of neurosurgicalsimulation for training and recertification, this simulatorrepresents an important step forward. The results from test-ing with 78 neurosurgical residents and fellows at the 2006annual meeting of the AANS seem to replicate some results(such as the mean and SD for distance between the finalposition of the catheter tip and the Monro foramen) from apreviously reported clinical study based on 98 proceduresperformed in an intensive care unit setting and hence lays astrong foundation for further investigation.

Future developments will include permutations to theoriginal data set to recreate slit or shifted ventricles for thepurpose of increasing complexity and simulating more ex-treme possibilities. Our goal is to continue with the devel-opment of procedure “modules,” each simulating a single

technical component (for example, bur hole trephination).Several modules could then be assembled in order to repro-duce an entire procedure using a part-task simulation para-digm. The ImmersiveTouch ventriculostomy simulator canalso make an impact in telemedicine education (for exam-ple, the data sets from the ImmersiveTouch simulator can bedownloaded at geographically dispersed sites).

Acknowledgments

We gratefully acknowledge the assistance of Ali Alaraj, M.D., andJay Banerjee.

Disclosure

Presented at the 2006 AANS annual meeting, this study was spon-sored by the AANS Young Neurosurgeons Committee, which doesnot claim the superiority of the ImmersiveTouch system over anoth-er system.

The ImmersiveTouch technology has been licensed to Immersive-Touch, Inc., by the University of Illinois at Chicago.

Coauthors Dr. Charbel and Dr. Banerjee both own stock in Im-mersiveTouch, Inc.

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TABLE 4Rectilinear distances (in mm) between the final

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Manuscript submitted July 24, 2006.Accepted December 15, 2006.Dr. Banerjee received support from National Science Foundation

(NSF) grant DMI-9988136, and National Institute of Standards andTechnology (NIST) Advanced Technology Program (ATP) Coop-erative Agreement 70NANB1H3014.

Address reprint requests to: P. Pat Banerjee, Ph.D., University ofIllinois at Chicago, Department of Mechanical and Industrial En-gineering, 3029 Engineering Research Facility (MC 251), 842 WestTaylor Street, Chicago, Illinois 60607. email: banerjee@uic.edu.

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A movie clip accompanies this article:

http://mfile.akamai.com/21489/rm/digitalwbc.download.akamai.com/21492/real.digitalsource-na-regional/ImmersiveTouch.ram

http://mfile.akamai.com/21490/wmv/digitalwbc.download.akamai.com/21492/wm.digitalsource-na-regional/ImmersiveTouch.asx